Town of Winthrop : Record of Deaths 1963, Part 46

Author: Winthrop (Mass.)
Publication date: 1963
Publisher:
Number of Pages: 574


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 46


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Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.


NOV 1 51963 AM


X PLACE OF DEATH


Suffolk (County )


Winthrop (City or Town)


No. Sturgis .... St.


The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No.


234


§ (If death occurred in a hospital or institution, Bay View Nursing sHomeits NAME instead of street and number)


PHYSICIAN - IMPORTANT


NAME John E ...... Conway


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


44 Belcher St.


St.


(If nonresident, give city or town and State)


Length of stay: In place of death.


. .. .. ... years.


1


months.


.days. In place of residence.


20 ... years.


months ..


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCEMarried


HEREBY CERTIFY,


That I attended deceased from


1063


how. 15


death is said to


have occurred on the date stated above, at


1:50 P.m.


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a) Pneumonia, bilateral


INTERVAL


12


BETWEEN


ONSET AND


DEATH


Juk


77


11 IF STILLBORN, enter that fact here.


Years.


. Months.


.Days


If under 24 hours


Hours


.. Minutes


13 Usual


Occupation :


Retired P.O. Clerk


(Kind of work done during most of working life)


14 Industry


or Business :


U.S. Postal Service


15 Social Security No.


None.


Tyrone


16 BIRTHPLACE (City)


(State or country)


Ireland


17 NAME OF


FATHER


Edward Conway


18 BIRTHPLACE OF


FATHER (City)


Tyrone


(State or country)


Ireland


19 MAIDEN NAME


(Signed)


Charles Liberan


M. D.


OF MOTHER


Catherine Cullinin


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


November 18,


19


63


7 NAME OF


FUNERAL, DIRECTOR


Arthur J. O'Maley


Winthrop, Mass


ADDRESS


Received and filed


NOV 18 1963


19


(Registrar)


PARENTS


21


Informant


(Address)


Anastasia .Conway.


Belcher St. Winthrop


1 HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:


(Signature of Agent of Board of Health or other)


Health officer


november 18, 1963


(Official Designatign) &


(Date of Issue of Permit)


TUE.V


R-301A 1


ERik the $ CTIONS R ERTIFICATE


ving F DEATH enter an one or each ) and (c)


not mean of dying, art failure. c. It means OT compli- ich caused


, if any, De rise to use


-


(a), se under- use last.


ons contrib- ath but not he terminal lition given C.


hapter 137, 4. requires to print or cause or death on ficates, and , Acts of ires Physi- int or type signature.


9-925686


3 DATE OF


NOV


DEATH


(Month)


(Day)


(Year)


4 L


et


1962, 5


I last saw he walive on


11/15/


1963


Ida If married, widow Hetasia Butler


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


Due To (b)


Due To (c)


OTHER


Cerebral Arteriosclerosis


CONDITIONS Cerebro Vascular Thrombosis


5 yrs. 6 mos


Was autopsy performed?


100


What test confirmed diagnosis ?


Clinical


5 Was disease or injury in any way related to occupation of deceased NO If so, specify


CHARLES


LIBERMAN


(PRINT OR TYPE SIGNATURE)


(Address) Wi Winthrop, Mass Date ...... 11/15/ 19 63


St.


Joseph's


West Roxbury


20 BIRTHPLACE OF


Tyrone


MOTHER (City)


(State or country)


Ireland


To be filed for burial permit with Board of Health or its Agent.


No


(Was deceased a


U. S. War Veteran,


[if so specify WAR)


(Usual place of abode)


15


1963


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


TOW.


11 12


C)


ERK


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons


to whom they have given bedside care during a last illness from disea0%/ 1 81963 AM related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.


5


6


IN


(THROP


RM R-301


burial permit d of Health Agent. CTIONS


OR CERTIFICATE


R TYPE R CAUSES EATH t enter han one for each b) and (c)


s not mean of dying, eart failure, tc. It means . OT compli- hich caused


ss, if any, ve rise to ause (a), the under- ause last.


ions contrib- eath but not the terminal dition given


X - PLACE OF DEATH


SUFFOLK (County)


WINTHROP


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


(City or Town making this return)


235


[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


2 FULL NAME.


DeCOURCEY, ..... BabyGirl


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(Was deceased a


U. S. War Veteran,


(if so specify WAR)


(a) Residence. No ....


115 Summit AVE. Winthrop


(Usual place of abode)


Length of stay : In place of death .......... years .......... months .......... days. In place of residence .......... years .......... months ......


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female


9 COLOR


3


10 SINGLE


MARRIED


(write the word) single


11 If married, widowed, or divorced HUSBAND of


(or) WIFE of


(Husband's name in full)


12


AGE.


......... Years ..


Months.


.Days


If under 24 hours


.Hours. /5 Minutes


13 Usual Occupation : (Kind of work done during most working life)


14 Industry or Business :


15 Social Security No.


16 BIRTHPLACE (City).


(State or country )


17 NAME OF


FATHER


Richard D DeCOURCEY


18 BIRTHPLACE OF


FATHER (City) WINTHROP, MASS


(State or country)


19 MAIDEN NAME


OF MOTHER


JEANNE A. VIENNEAU


20 BIRTHPLACE OF MOTHER (City) .. (State or country)


WORCESTER, MASS


2I Informant


RICHARD D. DeCOURCEY


( Address)


115 SUMMIT AVE WINTHROP


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : · Parpoh &. Sirianni (6)


(Signature of Agent of Board of Health or other) Health officer


Diovember 15 1963


(Official Designation) / (Date of Issue of Permit)


A TRUE COPY ATTEST:


1


(If nonresident, give city or town and State)


... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


(Day)


November


15,


1963


(Year)


4 I HEREBY CERTIFY


That I attended deceased from


nov.15


19 63


to .......


nov.15


1963


I last saw hEAlive on


11/15


..... 19 6 death is said to


have occurred on the date stated above, at 10- Am


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


PREMATURITY-50


(a)


Due To


PLACENTA ABRUPTIO -


PARTIAL


121ths


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signature)


M. D.


MYRON N. KING MID


(Print or Type Name)


(Address) ILLPLEASANTST Date.


nov. 15 ,63'. WINTHALER


WINTHROP CEMETERY 6 Place of Burial or Cremation (City or Town)


DATE OF BURIAL


NOVEMBER


15


063


7 NAME OF


FUNERAL DIRECTOR


Richel C. KIRBY INC


917 BENNINGTON ST. EAST BOSTON


Received and filed


NOV 15-1963


19.


(Registrar)


-932382


No.


WINTHROP COMMUNITY HOSPITAL


Registered No.


WINTHROP, MASS.


PARENTS


DIVORCED UNKNOWN


(Give maiden name of wife in full)


INTERVAL BETWEEN ONSET AND DEATH 2 HRS


(b)


(Month)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.


12


THROR


NOV 1 5196


RM R-304


X 1


PLACE OF DELIVERY No.


SUFFOLK (County )


WINTHROP


(City or Town)


WINTHROP COMMUNITY HOSPITAL


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)


To be filed for burial permit with Board of Health or its Agent.


Registered No.


236


(If death occurred in a hospital or institution, 3


3 DATE OF


DELIVERY


11/15/63


(Month )


(Day)


(Year )


4 SEX


X


Male .. .. Female ...


.. Undetermined


5 COLOR (if


determined)


W


6 THIS BIRTH (Check one)


Single ..


. Twin


Triplet.


7 IF MULTIPLE BIRTH, BORN :


1st .. . . . 2nd


3rd


FATHER


MOTHER


14


MAIDEN NAME


MARGARET F CROWLEY


PRESENT NAME


MARGARET F PEARCE


9


RESIDENCE, NO. 93 CLIFF AVE


CITY OR TOWN


WINTHROP


STREET


STATE MASS


RESIDENCE,


93 CLIFF AVE


CITY OR TOWN WINTHROP


STREET


STATE MASS


10 COLOR OR


RACE.


WHITE


11 AGE AT TIME OF


THIS DELIVERY


26


(Years)


16 COLOR OR


RACE.


WHITE


17 AGE AT TIME OF


THIS DELIVERY


( Years)


12 PLACE OF WINT HROP.


BIRTH


(City or Town)


MAS


(State or country)


18 PLACE OBSOMENSTILLE


BIRTH


(City or Town)


MUSS


(State or country )


13 OCCUPATION MC 04. 2010 il INSPECTOR


19


INFORMANT


ROLAND


PEARCE


20 PREVIOUS DELIVERIES TO MOTHER


(Do not include this fetus


pone


(a) How many children are


now living?


home


(b) How many children were


born alive but are now


dead ?


none


(c) How many previous fetal deaths of ANY gestation age ?


21 LENGTH OF


PREGNANCY


completed weeks


36


22 Weight Lb.//


OF FETUS


(or


Oz. Grams)


23 WHEN DID EETUS DIE?


Before


Labor


During Labor or Delivery Unknown


24 AUTOPSY Yes


No


25 FETAL DEATH WAS CAUSED BY : IMMEDIATE CAUSE Umbilical cord assumed (a)


Due To (b)


Due To (c)


OTHER SIGNIFICANT


CONDITIONS


none


26


WINTHROP


Place of Burial or Cremation


WINTHROP.


(City or Town)


DATE OF BURIAL


NOV 18


1963


27


NAME OF


FUNERAL DIRECTOR MAURICE W KIRBY


ADDRESS


WINTHROP.


Received and filed


NOV 18 1963


19


( Registrar )


A TRUE COPY ATTEST :


I HEREBY CERTIFY that this delivery occurred on the date stated 10.00 Am .. and product of conception was not a live birth. above at


Signature of Attending Physician or Medical Examiner : peper Stregone Joseph GREGORIE (PRINT OR TYPE NAME) 19 4 Washington QUE Address Winthrop


M.D.


Date 11/10-1963


I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued :


Paeph E Lireanna (3) (Signature of Agent of Board of ffealth or other ) Health officer nov18,1963


( Official Designation )


(Date of Issue of Permit )


In giving AUSE OF TAL DEATH o not enter ore than one use for each of (a), (b) and (c)


l or maternal lition causing l death (do use such is as stillbirth prematurity.) l and/or ma- al conditions. y, which gave e to above e (a), stating underlying e last.


ditions of fetus mother which have contrib- d to fetal th, but, in so as is known, e not related cause given (a).


10M-6-62-933404


2 NAME OF FETUS


(if given)


PEARCE , MALE


St.


give its NAME instead of street and number)


8


FULL


NAME


ROLAND PEARCE


FETAL DEATH


OF TOW; il 12. 1 i


SLEFFS


6


EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48, ACTS OF 1960.


Section 2A. "Examination of records and returns of illegitimate births, or abnormal sex births, or fetal deaths, .. . shall not be permitted except ... ".


Section 9A. When a child is born dead, after a period of genouoh 81960 AHss than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle, the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.


Section 12. ". .. No birth record of a child born out of wedlock or of a child of abnormal sex, and no record of fetal death shall so be transmitted to any other city or town."


Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.


RM R-301


I


PLACE OF DEATH


SUFFOLK


(County)


WINTHROP


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


(City or Town making this return)


Registered No. 232


[(If death occurred in a hospital or institution,


St. { give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


2 FULL NAME.


George Pappas


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(Was deceased a


U. S. War Veteran,


(if so specify WAR).


720


(a)


Residence. No.


42 Franklin Street


(Usual place of abode)


.. St .. Winthrop Mass


(If nonresident, give city or town and State)


Length of stay: In place of death .......... years .......... months.


2 days. In place of residence 2 years. ...... months. days.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


MALE


9 COLOR


WHITE


10 SINGLE


MARRIEDA


WIDOWED


DIVORCED


UNKNOWN


(write the word)


: married


11 If married, widowed! or divorced HUSBAND of


PAGONA SAGOULAS PAPPAS (Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


12


AGE. Years.


- Months.


Days


If under 24 hours


.Hours ........ Minutes


13 Usual Clu


Occupation :


RESTAURANT PROP.


(Kind of work done during most working life)


14 Industry


or Business :


Food


15 Social Security No ...


217-28-0025


MessIniA


GREECE


16 BIRTHPLACE (City)


(State or country)


17 NAME OF


FATHER


GEORGE PAPPAS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


messinia


GREECE


19 MAIDEN NAME


OF MOTHER


KATERINA STAVRIAniA


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


GREECE


MRS PAGONA PAPPAS


(wife)


42 FRANKLIN St. WINTHROP


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Tripoli 6 Lereanna (1)


(Signature of Agent of Board of Health or other)


Health Oficer


november 19.1963


(Official Designation)


(Date of Issue of Permit)


1X


A TRUE COPY ATTEST:


INTERVAL BETWEEN ONSET AND DEATH 15 mos


(a) ...


Due To


(b)


Metastatic Cancer of


Due (c) Esophagus and right/Lang from primary in left cur SIGNIFICANT 0 CONDITIONS


Tyr


Left Theumonectomy l' 1 gr.


Was autopsy performed?


What test confirmed diagnosi


Clinical operative pattolage


5 Was disease or injury in any way related to occupation of deceased ?/Vol If so, specify ....


(Signature)


Charles Liberman


., M. D.


CHARLES


LIBERMAN


(Print or Type Name)


(Address)


WINTHROP MASS Date 11/16/1963


WINTHROP CEMETERY WINTHROP 6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


JUAVRiST MAURiS


Cluster


ADDRESS 48 0. Common St. Lynn


19


Received and filed


NOV 19 1963


( Registrar )


932382


r burial permit d of Health Agent. CTIONS R ERTIFICATE


R TYPE CAUSES ATH enter an one or each ) and (c)


not mean of dying, art failure, c. It means or compli- ich caused


s, if any, ve rise to use (a), he under- use last.


ons contrib- ath but not he terminal dition given


X


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


Nov


16


1963


(Month)


(Day)


(Year)


YTHEREBY CERTIFY, That I attended deceased from 4 Llug


19.62


to ...


Now: 16,


1963


I last say hl.malive on


Nov. 16.


19.63 death is said to


have occurred on the date stated above, at


7:30 p.m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Cancer of Lurna


WIN HROF COMMUNITY HOSPITAL


No


7 NAME OF FUNK FAL MIRECTOR


Nov. 19


63


19.


PARENTS


MESSiniA


21 Informant


( Address)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : (1) Attending physicians will certify to such deaths only as those of persons 150 to whom they have given bedside care during a last illness from disease un- related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of- persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


TOW


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly. by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related To occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


12


MINY


CLERK


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


6


THROP.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the odoldas tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.


191963 PM


-


X 1 PLACE OF DEATH


Suffolk


(County)


Winthrop


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD


CERTIFICATE OF DEATH


Registered No.


238


(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT


Pasquale Graziose


2 FULL NAME.


(If deceased is a married, widowed or divorced woman, give also maiden name.)


4 Billerica Street


(a) Residence. No.


(Usual place of abode)


Length of stay: In place of death .......... years ..


3 monthsdays. In place of residence: 25 ve


.years


....... months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


white


10 SINGLE


MARRIED


WIDOWED


DIVORCEDdivorced


UNKNOWN


11 If married, widowed, or divorced


Esther Calo


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


12


AGE.78


2 days


Years ..


Months.


Days


Retired


13 Usual


Occupation


(Kind of work done during most of working life)


14 Industry or Business .. *****


15 Social Security No ....


017-14-5431


16 BIRTHPLACE (City).


(State or country )


Italy


17 NAME OF


FATHER


Engene Graziose


PARENTS


18 BIRTHPLACE OF


FATHER (City).


(State or country )


Italy


19 MAIDEN NAME


OF MOTHER


Maria (unknown)


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Italy


21 Informant


Eugene Graziose (10n)


(Addr


4 Sycamore Circle, W. Peabody, Mass


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: L'apl 6 Liveanne (A)


(Signature of Agent of Board of Health or other)


Health Officer


november 19, 1963


(Official Designation)


(Date of Issue of Permit)


X


A TRUE COPY ATTEST:


(Registrar )


male


4 I HEREBY CERTIFY, That I attended deceased from


Sept 24


.. , 1963


to ..


NOV. 17


63


I last saw hlualive on


NOV.16


196 2 death is said to


have occurred on the date stated above, at


9:15Am.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Bronchopneumonia


INTERVAL BETWEEN ONSET AND DEATH


Due To


(b)


Due To


(c)


-


OTHER


SIGNIFICANT


CONDITIONS


Pulmonary fibrosis


Was autopsy performed?


NO


What test confirmed diagnosis ?


Clinical


5 Was disease or injury in any way related to occupation of deceased ?


If so, specify


NO


(Signature)


Chela 1. Ferrera


M. D.


Charles J. Ferrera, M.D


(Print or Typs Name)


(ASHe Bennington St, E. Boston 11/18


19 63


St. Michael Cemetery


Boston


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Nov. 20,


19.


63


7 NAME OF


FUNERAL DIRECTOR


Vincent R. Rapino


9 Chelsea St., East Boston, Mass.


ADDRESS


Received and filed


NOV 19 1963


19


2-934553


RM R-301


r burial permit 'd of Health Agent. CTIONS OR ERTIFICATE


R TYPE CAUSES CATH enter han one or each ) and (c)


s not mean of dying, cart failure, c. It means . of compli- ich caused


s, if any, ve rise to use (a), he under- use last.


ions contrib- ath but not the terminal dition given


BESTEN 12-5-63


Bay View Nursing Home No


(City or Town making this return)


(Was deceased a


U. S. War Veteran,


no


if so specify WAR)


Boston


St.


(City or town and State)


3 DATE OF


DEATH


November 17, 1963


(Month)


(Day)


(Year)


(write the word)


If under 24 hours


Hours ........ Minutes


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE.


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT




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